AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 31, 2023

Notice of material change/amendment to contract

Update to Claim Payment Dispute process

Anthem Blue Cross and Blue Shield (Anthem) is updating language to the Claim Payment Dispute process outlined in our Provider Manual. Providing clearer timelines will assist in your understanding of the processes for resolving disputes when you disagree with an initial claim payment decision. The information below will be reflected in the next Provider Manual update later this year.

Effective July 1, 2023, if you disagree with the outcome of a claim, a Claim Payment Reconsideration, the first step in the Claim Payment Dispute process, must be submitted within 365 days from the date on the EOP unless otherwise required by State law or your Provider or Facility Agreement.

If you disagree with the outcome of the Claim Payment Reconsideration determination, a Claim Payment Appeal, the second step in the Claim Payment Dispute process, must be submitted within 90 days from the date of the determination of the Claim Payment Reconsideration.

Except in cases where the Provider or Facility presents evidence of an extenuating circumstance, Anthem will not consider requests submitted outside procedures set forth above. If a care provider submits a Claim Payment Reconsideration or Claim Payment Appeal outside the time frames above without evidence of an extenuating circumstance, the request is deemed ineligible and will not be considered. In such cases, care providers may not bill members for services rendered. 

Submitting a dispute 

The preferred method for submitting both Reconsiderations and Claim Payment Appeals is online through the “Disputes” function in Availity Essentials, where available, or in writing to the address listed in your Provider Manual.

To submit via Availity Essentials: After logging in, locate the claim you want to dispute using Claim Status from the Claims & Payments menu. If available, select Dispute Claim to initiate the dispute. From the Claims & Payments menu select Appeals to locate the initiated dispute, upload supporting documentation, complete the wizard and submit.

If the option to dispute a claim is unavailable, submit your request in writing to the address listed in the Provider Manual.

Please provide this information to your billing staff and/or office managers, and if you have any questions, contact your Provider Relationship Management associate.

Please note: This change does not apply to appeals regarding a clinical decision denial, such as a utilization management authorization or a Claim that has been denied as not medically necessary or experimental/investigational.  For more information on Clinical/Medical Necessity Appeals, refer to the Clinical Appeals section within the Provider Manual.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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PUBLICATIONS: April 2023 Provider News - Maine